approach to hypertension at primary care level

7/31/2019 Approach to Hypertension at Primary Care Level

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APPROACH TO

HYPERTENSION


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KEY FEATURE

PROBLEM (CASE 1)


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Mr. Wong, a 56-year-old gentleman,

sees you today because of URTI.You decide to check his BP and thereading is repeatedly 152/94 and

152/90 while seated. He had beenmonitoring his BP at homeoccasionally and the measurements

for the past 1 year ranged betweenSBP 140-160, DBP 90-100.


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Hypertension is defined aspersistentelevation of

systolic BP 140mmHgand/or

distolic BP 90mmHg


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There is a positive relationshipbetween raised BP and the risk ofdeveloping cardiovascular,

cerebrovascular and renal disease

The aim of identifying & treating high

BP is to reduce these risks


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Classification of BP for adult aged 18 orolder (JNC 7th report, 2003)

Category Systolic Distolic Prevalence in Malaysia(1996)

Normal/optimal

< 120 and 140 and


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Classification of BP for adult aged 18 orolder (JNC 7th report, 2003)

Category Systolic Distolic Prevalence in Malaysia(1996)

Normal/optimal

< 120 and 140 and


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Metabolic syndrome:Componentsof metabolicsyndrome

Waistcircum-

ferance (cm)

BP(mmHg)

FBS(mmol/L)

TG(mmol/L)

HDL(mmol/L)

NCEP ATP III

2004

3 out of 5criteria

> 90 (M)

> 80 (F)

130/85 5.6 1.7 < 1.0 (M)

< 1.3 (F)

IDF 2005

Waistcriterion +2 out of 4other criteria

> 90 (M)> 80 (F)

130/85 5.6 1.7 < 1.0 (M)< 1.3 (F)


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Question 1:

In the history taking,

what are the other aspectsthat you should elicit?

List up to 6 aspects


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Smoking status

Past medical history (esp diabetes andhyperlipidaemia)

Family history of hypertension or premature

death) Evidence of target organ damage

Symptoms of target organ damage (angina,

intermittent claudication etc)


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Diet history (salt and alcohol intake)

Drug history Level of physical activity

Symptoms suggestive of secondaryhypertension (intermittent headache,sweating etc)

Psychosocial factors that could influencethe course and outcome of the care of

this patient (e.g. family situation, workenvironment and educationalbackground)


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smoking status



death) Evidence of target organ damage (hx of CVA,

MI, LVH, renal disease etc)

Symptoms of target organ damage (angina,intermittent claudication etc)


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Risk factors for CVD:

Modifiable risk factors Un-modifiable risk factors

Hypertension Diabetes mellitis

Dyslipidaemia Cigarette smoking Microalbuminuria Estimated GFR 55 yr for men,> 65 yr for women)

Family history ofpremature CVD(male 1 relative


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Smoking status



death) Evidence of target organ damage

Symptoms of target organ damage (angina,

intermittent claudication etc)


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Possible Target Organ damageinclude:

Organsystem

Manifestations

Cardiac LVH, CAD, heart failure

CNS TIA, CVA/strokePeripheralvasculature

Absence of one or more majorpulses in extremities with or withoutintermittent claudication

Renal GFR


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Symptoms suggestive of secondaryhypertension (intermittent headache,sweating, palpitation, tremor etc)




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Secondary causes ofhypertension: Drug induced or drug related

(OCP, steroids, NSAIDs, COX 2 inhibitor,amphetamine, illicit drugs etc)

Primary hyperaldosteronism

Pheochromocytoma Cushing syndrome

Chronic kidney disease

Renovascular disease Thyroid or parathyroid disease

Coactation of aorta

Sleep apnea


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Secondary causes ofhypertension

Suggestive symptoms orsigns

Suggestedinvestigations

Phaeochromocytoma Paroxysmal headache,sweating, palpitatin,normotension between theseepisodes

24 hour urinarycatecholamine, CTor MRI of abdomen

Hyperaldosteronism Hypokalaemia (not essential) or

suggestive symptoms (muscleweakness, hypotonia, muscletetany, cramps, cardiacarrythmias)

Refer

endocrinologist

Renal disease Nocturia, dark urine, sallowcomplexion

RFT, GFR, albumincreatinine ratio,renal ultrasound,renal arteryimaging

Sleep apnoea Somnolence, snoring Sleep study


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Symptoms suggestive of secondaryhypertension (intermittent headache,sweating etc)




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Question 2:

List up to 3 tests/

investigations that youwould perform in this case.


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The aim of investigations

are:To determine the presence ofother cardiovascular risk factors

To determine the presence of andassess the extend of target organ

damage

To exclude secondary causes ofhypertension


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Baseline investigations should includ

Fasting lipid profile

Fasting blood glucose

Renal function tests (Sr. electrolyte,

urea, creatinine, uric acid)

UFEME and urine microalbumin

ECG

Other depending on the findings e.g. 24hour urinary catecholamine, echo etc


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C-Reactive Protein (CRP)

It is an acute phase protein associated withinflammation

The standard assays (used to monitorinflammatory states) can only detect CRPlevel >0.8mg/L but the levels of CRP used toassess atherosclerotic risk (hsCRP) aremuch lower


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Although not yet a therapeutic target, hsCRPhave been shown to predict the long-termrisk of MI, ischaemic stroke, PVD

In the primary prevention setting, AHA andCDC only recommend screening patients atmoderate risk (10 yr risk 5-20%), i.e.screening for hsCRP level is not

recommended for patients at low (10-yr risk 20%) because it is unlikely tomeaningfully alter management decision


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AHA and CDC do not recommend CRPscreening in patients with established CVD

Other inflammatory markers are VCAM-1,lipoprotein-associated phospholipase 2

hsCRP level (mg/L) Risk of cardiovascular disease< 1 Low

1-3 Intermediate

>3 High

> 10 To repeat as it is suggestive of acute inflammation


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Question 3:

What lifestyle changes would you

recommend to Mr. Wong?List up to 2 recommendations.


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Reduce salt intake (< 6g/day equivalent to

1 teaspoon of salt)

Reduce alcohol intake

(< 21 units for men and


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disease blocker

Uncomplicatedhypertensionwith no co-

morbidconditions

+ -Unless (1) women ofchild beaing age; (2)patients withevidence of incresed

sympathetic drive

++ ++ + -

Elderly with noco-morbidconditions

+++ + + + +++ +/-

Diabetes(withoutnephropathy)

+ +/- +++ ++ + +/-

Diabetes (withnephropathy)

++ +/- +++ +++ ++(only

nonhydropyridineCCB)

+/-

Coronary heartdisease

+ +++ +++ + ++ +

Heart failure +++ +++(metoprolol,

bisoprolol, carvedilol)

+++ +++ +(current evidence

available foramlodipine andfelodipine only)

+

Concomitant Diuretics blocker ACEIs ARBs CCBs Peripheral


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disease blocker

Non-diabeticrenovasculardisease

++ + +++ ++ +(only

nonhydropyridineCCB)

+

Renal arterystenosis

+ + ++(contraindicated in

bilateral arterystenosis)

++(contraindicated in

bilateral renal arterystenosis)

+ +

Peripheralvasculardisease

+ +/- + + + +

Dyslipidaemia +/- +/- + + + +

Gout +/- + + + + +

Asthma + - + + + -


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At diagnosis:

Patient education What is hypertension

What is the purpose of treating

hypertension Self BP monitoring

Advice on lifestyle changes e.g. smoking

cessation, exercise, salt and alcohol intakeetc


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Subsequent review:

Measure BP and other relevantparameter (e.g. glucose level inpatients with concurrent diabetes,

weight in overweight patients etc) tosee if target has been reached

Adverse effects of medications

Development of complications

C di i T BP


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Concurrent conditions Target BP

Adult > 65 yr (with no diabetes,chronic kidney disease orproteinuria 0.25g/day)

< 140/90

Adult < 65 yr < 130/85

Adults any age with diabetes < 130/85

Adults any age with renalinsufficiency

< 130/85

Adults any age with proteinuria

0.25-1.0g/day

< 130/85

Adults any age with proteinuria> 1g/day (in people with and

without diabetes)

< 125/75


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Adverse effects Thiazidediuretics

-blocker ACEIs CCBs ARBs

Constipation - - - + -

Cough angio-oedema

- - + - Rarereport

Dyspnoea - + - - -

Gout + - - - -

Headache - - - + -Hyperglycaemia + - - - -

Hyperkalaemia - - + - +

Hypokalaemia + - - - -

Impotence + + - - -

Lethargy - + - - -

Oedema - - - + -

Posturalhypotension

+ - - - -


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Effective combination therapy:Effective combination Comments

ACEIs + diuretics Appropriate for concurrent heart failure,diabetes and secondary stroke prevention

ARBs + diuretics Appropriate for concurrent heart failure,diabetes and secondary stroke prevention

-blocker + diuretics Cost-effective, evidence of mortality &cardiovascular benefit esp in elderly.However, may increase risk of new onsetdiabetes & increase glucose level indiabetics

-blocker + CCBs(dihydropyridine)

Appropriate for concurrent CAD

ACEIs/ ARBs + CCBs Appropriate for concurrent diabetesand/or dyslipidaemia


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Consider the following if target BP is

not reached on 3 drugs (includingdiuretics)

BP measurement artefact e.g.

inadequate cuff size Non-compliance

Secondary hypertension

White coat hypertension Volume overload in patients with

chronic kidney disease


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KEY FEATUREPROBLEM (CASE 2)


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Martha is a 58 yr old lady with 5 yr history

of hypertension. You have tried manyantihypertensive medications and have

little success in achieving target BP.

Today, she mentions that she is finding itvery difficult to stay awake during the day

even though she goes to bed exhausted

at 9pm each night. Her husband hadbeen sleeping in the spare bedroom dueto her snoring.


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Martha is 152cm tall, weights 90 kg,has a BMI of 39 and has a sedentary

life. She is a non drinker. She takesnaproxen everyday for an

osteoarthritic knee.


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Question 1:

Lists 3 factors from the

history that could becontributing to Marthas

resistant hypertension


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Obesity

Medication, NSAIDs in this case

Sleep apnoea


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KEY FEATUREPROBLEM (CASE 3)


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En. Jamal, aged 61 yrs gentleman, had seenyour colleague for the past 2 years for labile

BP. He is an anxious person who gets verynervous about his visits to the doctor. He hasnot received any medication to date for the

control of his BP by your colleague.3 months ago he purchased a home BPmonitor and on this device, he obtainedreadings of up to 255/105mmHg during periodof stress.


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On examining En. Jamal, you note a BP of140/90mmHg (pulse rate 72/min) whichincreases to 170/100mmHg (pulse rate 90/min)as the examination proceeds. After leaving himto rest for 10 minutes, his BP decreases to135/90mmHg when measured by your nurse


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Question 1:

List 2 differential diagnoses

for this scenario.


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White coat hypertension

Phaechromocytoma


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Question 2

Lists 2 tests/investigations

that you would performto confirm your diagnosis


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24 hour ambulatory BPmonitoring (ABPM)

24 hour urinary catecholamine


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24 hour ambulatory BP

monitoring Cardiovascular outcome are best related toBP recordings outside the clinic setting

Acceptable limits are:

< 135/85mmHg during the day

< 120/75mmHg during the night


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Monitor BP at clinic regularly

self monitoring at home

+ repeat ABPM at 1-2 yearly interval ifpatients has no:

other comorbidities such as diabetes or

renal disease

Low 10 year risk of developing CVD

Evidence of target organ damage


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KEY FEATUREPROBLEM(HYPERTENSION CASE 4)


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Gary, aged 66 yrs, had well controlled

hypertension since his mid 40s. Over the yrs,he has been treated with enalapril 10mg od,and his usual BP on this regimen had beenabout 130-140/ 80-90. Approximately 6months ago, he presented for his repeatprescription and his BP was 156/96. Onreview 2 months later, it was 162/98 and after

a further 2 months, it was 168/100. At thisstage, a diuretics was added, but a monthlater there had been little change in his BP


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Garys past history include an uncomplicatedMI at the age of 60 yrs, smoking relatedCOPD, and T2DM controlled on glipizide. He

also has stable intermittent claudication forseveral years and is able to walk about 150mon the flat. He has no angina since his MI and

generally feels fairly well


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Question 1Lists 3 likely reasons for the

loss of control of Garys BPover the past 6 months?


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Artherosclerotic renal artery stenosis,given the evidence of arterial diseases invarious locations (MI and PVD) and risk

factors: T2DM, smoking, age, gender

Change in compliance e.g. due todepression

Hyperaldosteronism

PhaeochromocytomaCushing syndrome


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QuestionIf you are suspecting renal

artery stenosis, lists 2 tests/investigations that you will

perform


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UFEME

RFT

Renal duplex ultrasound

Renal isotope scanning before and aftercaptopril challenge

Angiography angioplasty stenting

CE-CTA (contrast enhanced CTangiography)

CE-MRA (contrast enhanced MRangiography)


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approach to hypertension at primary care level

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